Thrombophilia

Nontapak Thiangpak

Outline
Introduction Anticoagulant mechanisms Antithrombin deficiency Protein C Anticoagulant Pathway Protein C deficiency Protein S deficiency Discovery of APC resistance/FV Leiden

Identification of a prothrombin mutation

Introduction

Venous thromboembolism is a major medical problem, affecting 1 in 1000 individuals annually. Multifactorial disease; circumstantial and genetic mechanisms.
Virchow discussed 3 broad categories of factors contributing to venous thrombosis and pulmonary embolism.

Introduction

Genetic and circumstantial risk factors affecting one or more of the 3 categories of Virchows triad. Circumstantial factors;
Increasing

age. Immobilization. Surgery. Pregnancy. OCP. Hormone replacement. Inflammatory conditions.

Introduction

Most common is thrombosis in the lower limbs.

Genetic risk factors affect the natural anticoagulant mechanisms; imbalance between procoagulant and anticoagulant.

Multiple anticoagulant mechanisms control blood coagulation

Anticoagulant Mechanisms

Tissue factor pathway inhibitor (TFPI); binds and inhibits newly formed FXa that is associated with the TF-FVIIa complex.
The activated coagulation enzymes can all be inhibited by the circulating serine protease inhibitor (serpin) antithrombin (AT). Regulation of the 2 cofactors FVIIIa and FVa by the protein C (PC) anticoagulant system.

Antithrombin deficiency

Antithrombin deficiency

As early as 1905, Morawitz proposed the concept of antithrombin.

1963 an assay for AT in plasma was presented. 1965 Egeberg reported the presence of AT deficiency in a family.

Antithrombin deficiency
AT is a multifunctional serpin, inhibiting essentially all the active enzymes of the coagulation pathway. AT is a slow inhibitor, but the heparan sulfate (HS) family of glycosaminoglycans present on intact endothelium stimulates its inhibitory activity. The AT-binding region in heparin has been localized to a pentasaccharide sequence.

Antithrombin deficiency

No case of type I homozygous AT deficiency has been described.

There have been several type II homozygotes described with mutations in the heparin-binding region ofAT. Heterozygous type I AT deficiency is relatively rare in the general population; 10-fold increased risk of thrombosis.

Protein C Anticoagulant Pathway

Protein C anticoagulant pathway

Protein C was isolated and identified as a vitamin Kdependent protein by Stenflo in 1976. Anticoagulant properties after its activation by thrombin. Thrombin itself is a poor activator of protein C.
Thrombomodulin (TM) as a cofactor for the reaction discovery by Owen and Esmon in 1981.

Protein C anticoagulant pathway

TM is present on the surface of endothelial cells. Thrombin binds with high affinity to TM.
Loss of the procoagulant activities of thrombin and gain of the ability to activate protein C. Concentration of TM in the microcirculation is crucial for local protein C activation. In recent years, an endothelial cell protein C receptor (EPCR) has been identified.

Protein C anticoagulant pathway

APC inhibits the coagulation pathway by specifically cleaving of peptide bonds in FVIIIa and FVa. APC is slowly inhibited by either the protein C inhibitor (PCI) or by 1antitrypsin.

Protein C anticoagulant pathway

Soon after the report on protein C, DiScipio discovered protein S. Walker showed that protein S functions as a cofactor to APC. 2 forms in plasma; free protein S (30-40%) complex with C4b-binding protein (C4BP). Free protein S serves as an APC cofactor. Bound protein S provide local control of complement system activation.

Protein C anticoagulant pathway

FVIIIa and FVa are both highly sensitive to APC.

The activity of APC is stimulated by protein S.

Protein C deficiency

Protein C deficiency

In 1981, Griffin et al were the first to describe heterozygous protein C deficiency in a family with a history of recurring thrombosis. Homozygous protein C deficiency was found to be associated with severe neonatal purpura fulminans. Type I deficiency; decreased protein concentration. Type II deficiency; normal protein C concentration, low protein C activity.

Protein C deficiency

Protein C deficiency was found slightly more often than AT deficiency, but still in less than 5%.

Protein S deficiency

Protein S deficiency

In 1984, the first thrombosis patients with protein S deficiency were described.

Type I; free and total protein S levels were low. Type II; functional deficiency. Type III; only the free form was low.

Discovery of APC resistance/FV Leiden

Discovery of APC resistance

In studies of thrombosis cohorts performed during the 1980s,

Deficiencies of AT, protein C, and protein S were identified in lessthan 10%. Even though positive family histories were present in up to 40% of the cases.

Discovery of APC resistance

1993 the discovery of APC resistance. APC resistance was found to be highly prevalent (20-60%) among thrombosis patients. 1994 The protein identity was coagulation factor V. Suggesting APC resistance to be caused by a mutation in the FV gene. The mutant FV is commonly referred to as FV Leiden.

Identification of a prothrombin mutation

Prothrombin mutation

The mutation is located in the 3 untranslated region of the prothrombin gene; does not change the structure of prothrombin.
Slightly increased plasma levels of prothrombin, a lifelong 3-to 4-fold increased risk of venous thrombosis.